How to Reshape Your Approach to NOWS, Today

Adam Czynski, DOAssistant Professor of PediatricsWarren Alpert Medical School

Brown University Director, Newborn Nursery

Clinical NeonatologistWomen & Infants Hospital

• 8th Largest Birthing Hospital in the Country

• Largest Birthing Hospital in Rhode Island

– 9,100 Births a year

• Pediatric Services include NICU and Newborn Nursery

• 62% of Payer mix is either Self Pay or Medicaid / Medicare Health Plans

Rhode Island’s Opioid Crisis

•Drug overdoses in Rhode Island are a public health crisis. The number of deaths are increasing

•RI ranks 7th in the nation in overdose deaths from prescription drugs (Statistica,2015)

•Between 2009-2015 overdose deaths for women have increased by 63% (RI DOH,2015)

•RI has the nations highest rate of illicit drug use per capita and non-medical use of prescription opioids and ranks far above the national

average

Overdose Deaths In Rhode Island

Overdose Deaths In Rhode Island

Bateman et al, Anesthesiol. 2014

14.4 % of Pregnant women prescribed an opioid during pregnancy

NAS Statistics in Rhode Island

• NAS rates in RI have more than doubled in the last decade

2005 44/10.000 births2010 56/10,000 births2015 95/10,000 births

• 97% of the 95 births in 2015 were born at Women & Infants, of the 97%,

• 98% were managed in the Mother Baby Unit• The average charge is $70,506.00 compared

regionally the average is $93,815.00

Patient Story

• Baby M was born on in February 2016• Involved parents • Both parents on methadone• Total stay was 38 Days• Total morphine need was

– 50.6 mg total– 18.7 mg a day– 2.3 mg /kg/ dose

• Stayed on 4 different hospital units• Parents Felt Judged and Powerless

Support and EmpowermentJudged and Powerless

Knowledge and Understand

Understanding Opioid Addiction

• Understanding the biochemistry helps to better assess NOWS

• Understanding opioid effects on the body is important to understand the need for treatment

Opioids and Pleasure

Kosten et al. Sci Pract Perspect. 2002

Kosten et al. Sci Pract Perspect. 2002

Opioids and Physical Dependence

Kosten et al. Sci Pract Perspect. 2002

Opioids and Physical Dependence

Kosten et al. Sci Pract Perspect. 2002

Opioids and Physical Dependence

Kosten et al. Sci Pract Perspect. 2002

Opioids and Physical Dependence

• Tolerance is the drive to take larger doses of opioids to achieve the same feelings of pleasure

• Dependence is the need for opioids to treat the effects of an upregulated locus ceruleuscausing unregulated norepinephrine release

Tolerance and Dependence

Patient Story

• Baby M was born on in February 2016

• Involved parents

• Both parents on methadone

• Total stay was 38 Days

• Total morphine need was– 50.6 mg total

– 18.7 mg a day

– 2.3 mg /kg/ dose

• Stayed on 4 different hospital units

Problem Identification

• Poor Communication

– Healthcare Provider to Healthcare Provider

– Healthcare Provider to Family

• No Central Treatment Location

• Reduced focus on Discharge

• Flexibility with Protocol “Provider Preference”

• Inconsistency with Rounding

• Families felt judged and powerless

The Journey Begins

Plan

DoStudy

Act

Plan

Develop a new model of care for babies with NAS

1. Centralize our Care

2. Improve Communication Between the Family and Team

3. Create Structure

4. Empower our Patient’s Family

5. Discharge Begins on Day 1

Centralize Location of Care

• Model of care changed from a boarder nursery to a more family centered approach and became centralized

• NAS Task Force initiated• Criteria for “Rooming In” was developed• Education and support for the nursing staff is ongoing• First line of therapy for babies with NAS is non-

pharmacologic , with clustered supportive care• Care is a team approach with parents included every

step of the way• Developed “Cuddler” program

Improve Communication:

“I get 6 different messages from 4 different people”- Every family in a hospital

Team Communication

• Expanded the Team to including all stakeholders

• The Team became the Family Care Team

Family Care Rounds

Family Care

Rounds

Doctors

NP

Nursing

Social Work

Occupational Therapy

Case Management

Chaplin

Community Partners

Family

Family

NP

Nursing

Social Work

Case Management

Chaplin

Community Partners

Doctors

Occupational Therapy

Family Care Rounds

Family

Doctors

NP

Nursing

Social Work

Occupational Therapy

Case Management

Chaplin

Community Partners

• Family Care Rounds Start Every

Day at 13:30

• Conducted in the Patient Room

with entire team

• Family responsible to update

team about previous 24 hours

• Date of Discharge is discussed

everyday

IMPLEMENTATION

Implementation

• May 2016 we went live with our Family Centered Care Model

• Babies kept in the room with the mother

• Nursing and Family partnered to assign NAS Scores

• Families were informed of our new model during prenatal consults

Retrospective cohort study conducted at Women & Infants Hospital (WIH) with infants born between May 2015– April 2017.

• Infants born between May 2015-April 2016 were treated using the WIH standard of care for NAS infants.

• Infants born between May 2016-April 2017 were treated using Family Care Rounds in addition to the WIH standard of care.

• Length of stay (LOS), length of treatment (LOT), and total number of morphine doses were analyzed using generalized linear models with a Poisson distribution.

• Covariates included birth weight, gestational age, and DCYF involvement. Covariates were selected based on conceptual reasons, published literature, characteristics that differed between groups, and were not highly correlated.

Table 1. Caregiver and infant characteristics by type of care

N (%)or Mean (SD)

Family

Care

Rounds

(n = 20 )

WIH

Standard of

Care

(n= 16)

P-

Value

Caregiver Characteristics

Race

White 16 (84.2%) 12 (92.3%) 0.496

Public Insurance 18 (94.7%) 12 (92.3%) 0.780

DCYF Involvement 11 (55.0%) 3 (18.8%) 0.027

Infant Characteristics

Gender (boy) 8 (40.0%) 9 (56.3%) 0.332

Birth weight (g) 3188 (564) 2895 (480) 0.107

Discharge weight (g) 3447 (928) 3239 (616) 0.327

Gestational Age (weeks) 38.7 (1.8) 38.5 (1.5) 0.686

Conclusions

Buprenorphine

Take Home Message